Registered Nurse - (RN) Complex Case Care Coordinator

Wellstar Health Systems, Inc.; Austell (GA); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Relocation assistance

Job summary

Wellstar Cobb Hospital in the United States is seeking an RN Complex Care Coordinator to assess complex patient needs, coordinate across the care continuum, and engage with patients and families to ensure all care requirements are met. The role acts as a clinical and social resource to the care team and drives timely, safe discharge planning.

Key duties include conducting comprehensive assessments, managing a select complex caseload, connecting families with community-based services, and

Qualifications

• Comprehensive clinical and psychosocial assessment skills
• Care coordination abilities across care continuum
• Discharge planning and patient/family engagement
• Interdisciplinary team collaboration and communication

Responsibilities

• Provide comprehensive clinical and psychosocial assessments for complex patients to advance discharge planning.
• Manage a caseload of complex patients in coordination with the patient care team.
• Share information about community services and guide patients/families on multi-system factors affecting care.
• Serve as a specialist on psychosocial, discharge needs and end-of-life planning.

Job description

Work Shift

Day (United States of America)

Come join our Cobb Hospital Care Coordination team!

About the Facility

Learn more about Wellstar Cobb Hospital, including our teams, culture and campus environment:

locations/hospital/cobb-medical-center

Hours: FT Days

Relocation assistance for eligible candidates

Job Summary

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.

Specific functions within this role include:

• Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
• Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
• Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
• Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support